Observership Program Application

Applicant’s Information

Date: _______________
Have you been a visiting observer at Cleveland Clinic Florida before?  Yes  No If yes, Date: ________________________

_____________________________________________________________________________________________________________
Last name First Name MI

Address: _____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Phone (area/country code) ______________________________________________ Gender: Male  Female

E-Mail: _______________________________________________ Date of Birth: ___________________________________________

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Education/ Training

Medical School Name: ___________________________________________ Country of Medical Degree: _________________________

Country of Practice: _________________________________ Specialties of Practice: ____________________________________

Type of Degree: _____________ *** PLEASE SUBMIT A COPY OF YOUR MEDICAL SCHOOL DIPLOMA***

Do you have a Florida Medical License Number?  No Yes If yes, please submit a copy of your medical license.

INTERNATIONAL MEDICAL GRADUATES ONLY:

Are you certified by the Educational Commission for Foreign Medical Graduates (ECFMG)?

 No  Yes If yes, Please submit a copy of your certificate

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REQUESTED ROTATIONS:

Department Dates Department Dates

Immigration
 Permanent Resident Visitor’s (B) Visa  J-Visa  H-visa  US Citizen SS#: _______________________________________

For International Observers only: ( Please submit copy of resident card, passport and visa)

Country of Origin: __________________________ Passport #: _____________________ Expiration Date: _____________________

Visa #: __________________________ Visa Expiration Date: _____________________

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Health Requirements

Visitors are required to provide proof of immunization, specifically:

1. Varicella Rubella, Measles: Vaccinated (or) Titers showing immunity

2. Tuberculosis: PPD negative (or) Chest X-ray negative (< 1 year)
3. Proof of hepatitis B immunity (serology)

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Declaration

I certify that the information given on this form is true, accurate and complete. I understand that
any false information will cause my disqualification.

Signature: ____________________________________________ Date: ________________________